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Center for Disease Control Biohazard Division INTERNAL DEPARTMENT USE ONLY – NOT TO BE DISTRIBUTED From: Agent Arzola To: Assistant Director Schaller Subject: Updated briefing for Case Number #BD1347 Upon receipt of new information a secondary review of this case was ordered. Our findings are outlined below. Summary: For roughly 100 years scientists have claimed that the medieval Black Death was a case of Bubonic Plague. This was “proven” by comparing the medieval accounts to modern outbreaks of the Plague. Since Bubonic Plague is caused by fleas on rats it has been assumed that the Black Death was caused by the same factor. You will find this stated as fact in most modern sources. However, recent evidence has led some to question that theory because there are no records of massive amounts of sick and dead rats in areas where the Black Death spread. The truth is we simply cannot state with 100% certainty what caused the Black Death. The Theories: It is still very possible that the Black Death was Bubonic Plague spread by rats. However, if that is not the case we do have some other options to investigate. The doctors of the Medieval period believed the disease was caused by a “miasma” which is, in modern language, bad air. They didn’t understand the concept of germs at the time but this may give us a clue. The most common explanation of the time, however, was that the disease was a punishment from God. Though this may sound ridiculous we have certainly seen stranger things and the evidence is there to support the theory. Threat Level: Very High Determining the cause of this disease is very important. If the Black Death was not Bubonic Plague we need to find out. We need to be ready to act if this disease returns. There are many reasons why this may not be Black Death so take this investigation very seriously. We do not want to cause a panic in the people so this investigation should remain classified. Assignment: Use the exhibits provided to determine the cause of the Black Death and how it spread so that we can better prepare for an outbreak.

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Exhibit B: Disease Descriptions

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Description of the Medieval Black Death Those infected felt themselves penetrated by a pain throughout their whole bodies and, so to say, undermined. Then there developed on the thighs or upper arms a boil about the size of a lentil which the people called "burn boil". This infected the whole body, and penetrated it so that the patient violently vomited blood. Then there developed gland boils on the groin, the thighs, the arms, or on the neck. At first these were of the size of a hazel nut, and developed accompanied by violent shivering fits, which soon rendered those attacked so weak that they could not stand up, but were forced to lie in their beds consumed by violent fever. Soon the boils grew to the size of a walnut, then to that of a hen's egg or a goose's egg, and they were exceedingly painful, and irritated the body, causing the sufferer to vomit blood. The sickness lasted three days, and on the fourth, at the latest, the patient succumbed. Michael Platiensis (1357)

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Description of Modern Bubonic Plague Bubonic plague symptoms appear suddenly, usually 2–5 days after exposure to the bacteria. Symptoms include: Chills General ill feeling High fever Muscle Cramps Seizures Smooth, painful lymph gland swelling called a bubo, commonly found in the groin, but may occur in the armpits or neck, most often at the site of the initial infection (bite or scratch) Pain may occur in the area before the swelling appears Skin color changes to a pink hue in some extreme cases Bleeding out of the ear will begin after 12 hours of infection Other symptoms may include heavy breathing, continuous blood vomiting, aching limbs, coughing, and extreme pain. The pain is usually caused by the decaying or decomposing of the skin while the person is still alive. Additional symptoms include extreme fatigue, lenticulae (black dots scattered throughout the body), delirium and coma.

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Symptoms of the Bubonic Plague

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Exhibit C: Historical Plagues

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Office of the Medical Examiner 14 Abbey Road London, England REPORT OF INVESTIGATION BY THE MEDICAL EXAMINER NAME: John Shoemaker SEX: male AGE: 23 CAUSE OF DEATH: (mark one only) violent disease sudden suspicious, unusual or unnatural Investigating Agency: FBI (Biohazard Division) x PROBABLE CAUSE OF DEATHMANNER OF DEATH Multiple organ failure as a result of disease natural suicide homicide accident unknown I hereby declare that after receiving notice of the death described above I took possession of the body and made inquiries regarding the cause of death in accordance with Section Date: ______________Signature: ___________________ Figure 1 shows a sketch of the deceased shortly after death. He first developed red boils on the thighs or upper arms a about the size of a bean. Eventually this infected the whole body, and penetrated it so that the patient violently vomited blood. This vomiting of blood continued without intermission for three days. He also developed larger gland boils on the thighs, the arms, and on the neck. At first these were of the size of a hazel nut, and developed accompanied by violent shivering fits. Soon the boils grew to the size of a walnut, then to that of a hen's egg. The sickness lasted three days, and on the fourth, at the latest, he succumbed and died. It is unknown what disease caused this. Figure 1 x x

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San Francisco – 1906 The largest Plague scare in US history was part of this pandemic. Following the massive earthquake in 1906 rats were driven out of the sewers and into the streets of San Francisco. A massive extermination effort (over 10 million rats were killed) prevented the disease from spreading to many humans. This helped prove rats were the cause of this particular Plague. India The latest worldwide outbreak was in India in Like the other Plagues recorded there was first a massive die-off of rats in the streets. Once again actions like extermination helped to stop the spread and prove once and for all that the fleas on rats were both the carrier, and transmitter, of the Bubonic Plague. But what if the Medieval Black Death wasn’t actually the Bubonic Plague? Medieval texts New Take on an Old Disease Vol. CLII, No. 71 April 17, 2004 and as a result some in today’s modern scientific community are questioning the true cause of the Medieval Black Death. Other Plagues in History “The Third Pandemic” The third major Bubonic Plague breakout in history occurred in the 1850s and, once again, originated in Asia. It spread, ultimately, to India, Russia, Hawaii and San Francisco. It lasted roughly fifty years. It was during this outbreak that scientists first came to believe that the Plague was spread by rats. Just before the Plague was seen in humans there was a massive die-off of millions of rats. San Francisco, 1906 The black rat (Rattus Rattus) 35 36

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Exhibit D: The Miasma

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As may be seen on picture here, In Rome the doctors do appear, When to their patients they are called, In places by the plague appalled, Their hats and cloaks, of fashion new, Are made of oilcloth, dark of hue, Their caps with glasses are designed, Their bills with antidotes all lined, That foulsome air may do no harm, Nor cause the doctor man alarm, The staff in hand must serve to show Their noble trade where'er they go. -Renaissance Poem As may be seen on picture here, in Rome the doctors do appear. When to their patients they are called, in places by the plague appalled. Their hats and cloaks of fashion new, are made of oilcloth, dark of hue. Their caps with glasses are designed, their bills with antidotes all lined, that foulsome air may do no harm, nor cause the doctor man alarm. The staff in hand must serve to show their noble trade wherever they go. The doctors wore thick coverings over their hands and bodies. Their cloaks were coated with wax on the inside to help seal out the disease. It seems to have helped. Few doctors appear to have gotten sick. The staff was used to keep infected people at a distance. The hat was likely just a way to identify a person as a doctor.

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“Plague Doctors” stuffed their masks with herbs and flowers to keep out the bad smells that many doctors believed was causing the disease. The glass eye coverings helped to seal out the smell. It is interesting that though doctors of the time didn’t really know about germs these techniques are not very different from modern biological safety techniques. A ring, a ring of roses, A pocket full of posies- Ashes, Ashes we all fall down. Another indication of bad smells being thought to cause the disease is the children’s rhyme shown here. Many believe this rhyme references the Black Death and recommends carrying around posies (flowers) to keep out bad smells.

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Exhibit E: Letter from a Monk

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Dearest Mother, I am so glad to finally write to you and that these horrible days are now behind us. We have lost so many of our brothers from the monastery and I weep for little Maria and Phillip. I thank God that you have survived the pestilence. Many are saying that it will be back soon but I know it is now gone. God has sent us this pestilence. Our people had become too corrupt and greedy. There has even been evil within the church. We failed God in the Crusades. He commanded us to regain the Holy Land and we did not. Our weak faith has brought this on us. I know many say it was caused by the miasma, the bad odors, but that cannot be. If that were true then where has the pestilence gone now? The stench of death still hangs in the air. Why are no more getting sick? Simple. God, who brought this disease, has seen to forgive us and has now taken it away. Many have asked me why God would allow monks like me to die. They do not see the true miracle. Our Pope has not shown even a hint of sickness even as those around him did. God protected him. There is no other way to explain the perfect health of God’s representative than to understand that this was from God. We must learn to serve God always. His love has taken this pestilence away. We must work to make sure it never returns. Sincerely, John Smythe

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Exhibit F: Black Death Map

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The Black Death was first reported in Messina, Italy, on the island of Sicily, in October, 1347, and then moved through Europe. Below are the likely dates of the arrival of the Black Death in a variety of cities: Genoa, Italy - January, 1348 Venice, Italy - February, 1348 Marseilles, France - February, 1348 Paris, France - June, 1348 Liege, Belgium - June, 1349 London, England - July, 1349 Hamburg, Germany - June 1350 Genoa Messina

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Exhibit G: Extermination

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NOTICE OF EXTERMINATION On this Monday the Fourteenth of July in the Year of Our Lord 1349 be it proclaimed that all house pets will be exterminated. It has been decided that animals are carriers of the pestilence. These animals live in our homes causing the problem to be even worse. This action is needed to keep us safe.

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Exhibit H: New Cases

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CBS NEWS/ September 5, 2012, 5:17 PM 7-year-old Colorado girl contracts "black death" bubonic plague Sierra Jane Downing, from Pagosa Springs, Colo., watches while her mother Darcy Downing talks about her recovery from Bubonic Plague at the Rocky Mountain Hospital for Children at Presbyterian/St. Luke's during a news conference Sept. 5, 2012, in Denver. (CBS/AP) DENVER - A 7-year-old girl is recovering in a Colorado hospital after being diagnosed with the Black Death, scientifically known as the bubonic plague. The parents of 7-year-old Sierra Jane Downing thought she had the flu when she felt sick days after camping in southwest Colorado. When she had a seizure, her father rushed her to the local hospital in Pagosa Springs. The emergency room doctor who saw Sierra Jane for the seizure and a 107-degree fever late Aug. 24 wasn't sure what was wrong either, and called other hospitals before the girl was flown to Denver. A pediatric doctor racing to save the girl's life at Rocky Mountain Hospital for Children got the first inkling that she had bubonic plague. Dr. Jennifer Snow first suspected the rare disease after factoring in the girl's symptoms, a history of where she'd been and an online journal's article on a teen with similar symptoms. "If she had stayed home, she could've easily died within 24 to 48 hours from the shock of infection," Snow said. It was the first bubonic plague case Snow and her colleagues had seen. The bubonic plague hasn't been confirmed in a human in Colorado since 2006, when four cases were reported, according to state health officials. But, this past June, a man in Oregon contracted the disease after a cat bit him while he was trying to take a rat out of its mouth. Federal health officials say that on average, seven cases are reported in the U.S. each year. Sierra Jane's heart rate was high, her blood pressure was low, and she suffered a swollen lymph node in her left groin so painful it hurt to undergo the ultrasound that helped detect it, Snow said. However, the girl is recovering and could go home within a week, doctors said Wednesday. "She's just a fighter," said her mother, Darcy Downing. Downing said her daughter may have been infected by insects near a dead squirrel she wanted to bury. Plague is generally transmitted to humans through the bites of infected fleas but also can be transmitted by direct contact with infected animals, including rodents, rabbits and pets. It can be treated with antibiotics. Symptoms of the bubonic form of the plague in humans include fever, chills, headaches, vomiting, diarrhea and swollen lymph nodes in the groin, armpit or neck areas. Pneumonic plague, which is an infection of the lungs, can include severe cough, difficulty breathing and bloody sputum. The bubonic plague wiped out at least one-third of Europe in the 14th century. Today, it can be easily treated with antibiotics. The FDA approved a Johnson & Johnson antibiotic in April 2012 to combat the disease. In laboratory tests, 94 percent of the monkeys given the treatment were cured of the disease and survived.